内镜经鼻颅底肿瘤切除术中的止血策略

Strategy of intraoperative hemostasis in endonasal endoscopic surgery of skull base tumor

目的探讨如何在内镜经鼻颅底良性肿瘤切除手术中,针对不同的出血方式采取科学的综合止血措施。方法回顾性分析了首都医科大学宣武医院耳鼻咽喉头颈外科2012年2月~2016年4月收治的161例颅底良性肿瘤患者,全部患者行内镜经鼻手术入路。将全部患者分为两组:2014年2月之前住院的病例74例,未采取新材料、新技术止血措施的为对照组。术中血管出血主要应用双极或单极电刀电凝止血,创面渗血主要采用纱条、纱布或明胶海绵压迫止血。2014年2月以后住院的患者87例,采取新型止血材料以及射频等离子刀等新技术止血措施的为实验组。实验组采取综合止血方法,如术前根据影像学资料分析肿瘤的供血血管,术中尽可能先解剖分离相关责任血管,以射频等离子刀予以切断、凝结;切除肿瘤时,以射频等离子刀切割、凝结交替进行,逐步分离肿瘤;手术创面毛细血管渗血,采取速即纱(Surgicel)压迫止血、或射频等离子刀凝结止血;海绵窦等大的静脉窦出血,采用速即纱或Surgiflu/Surgifoam填塞止血。对于术中的出血量、止血方法、手术时间,进行记录、对比分析。结果所有患者术前均行常规实验室化验检查、颅底CT及MRI检查、部分患者行头颅DSA检查。对照组患者中,术中出血量50~2 100 ml,平均410+50 ml;手术时间50~310 min,平均120+20 min。实验组患者中,术中出血量50~1 600 ml,平均280+50 ml;手术时间45~220 min,平均90+20 min。实验组与对照组两者相比较,出血量及手术时间都明显减少,差异具有统计学意义(P<0.05)。出血量与肿瘤的性质、部位、血供相关,肿瘤血供丰富、位置深在、周围解剖结构关系复杂者,出血量较大;与肿瘤的大小无关;与手术时间无关。结论熟练掌握内镜颅底外科相关区域的三维解剖,尤其是重要血管神经的走行,是手术成功的前提;科学运用止血新材料、新技术,针对不同出血方式采取相应的止血方法,以保持术野清晰,是手术成功的关键。

Objective To explore the scientific comprehensive measures of intraoperative hemostasis for the management of hemorrhagic events due to different causes during endoscopic endonasal skull base surgery （EESBS）. Methods Clinical data of 161 patients who received EESBS as the treatment for skull base benign tumor between Feb 2012 and April 2016 were analyzed retrospectively. They were divided into two groups. 87 patients who were hospitalized after Feb 2014 were included in the experiment group and managed with comprehensive measures including new hemostatic agents and techniques available for reducing intraoperative bleeding, such as Surgicel, Surgiflu/Surgifoam, low-temperature plasma radiofrequency ablation. During preoperative and intraoperative assessment, patients at high risk of serious hemorrhagic complications should be recognized. Appropriate choices of different techniques for control of bleeding that relied mainly on the source of hemorrhage, the tissue involved, and the proximity of critical neurovascular structures were made. At the same time, 74 patients who were hospitalized before Feb 2014 were selected as control. The traditional medical gauze, pistol-grip or single-shaft electrocoagulator constituted the most important instruments available for reduction of intraoperative bleeding in EESBS. The volume of intraoperative blood loss, method of intraoperative hemostasis and operating time were recorded and statistically analyzed. Results All patients underwent routine laboratory tests, skull base CT and MRI examinations, and some cases underwent skull digital subtraction angiography （DSA）. In the control group, the volume of intraoperative blood loss was 50 - 2 100 ml with an average of 410 ±50 ml, and the operating time was 50 - 310 min with an average of 120 ± 20 min. In the experimental group, the volume of intraoperative blood loss was 50 1 600 ml, an average of 280 ± 50 ml, and the operating time was 45 -220 miu with an average of 90± 20 min. The volume of intraoperative blood loss and operating time of the experiment group were significantly less than those of the control group, the differences were both statistically significant （ both P 〈 0.05 ）. The volume of blood loss was related to the nature, site and blood supply of the tumor. Massive intraoperative bleeding was more likely to occur in tumors with abundant blood supply, deep location and complicated surrounding anatomical structures. The analysis showed no relation of blood loss volume with the size of tumor and the operating time. Conclusion For the success of operation, the precondition is to master the three-dimensional anatomy of the area of EESBS, especially the important vessels and nerves. Wisely using hemostatic new materials and techniques to reduce intraoperative bleeding and to maintain clear operation field is the key for successful operation.